WASH in Guinea, Liberia and Sierra Leone (19 May 2015)

Thematic Note – 19 May 2015
Crisis Overview
WASH in Guinea, Liberia, and Sierra Leone
The Impact of Ebola
This assessment of the known and probable impact of the Ebola outbreak on the WASH
sector in Liberia, Sierra Leone and Guinea is based on a secondary data review and
information collected by ACAPS analysts in the field.
Need for international
assistance
Expected impact
Not required
Low
Moderate
Significant
Insignificant
Minor
Moderate
Significant
Urgent
X
Major
X
Crisis Overview............................................................................................................................ 1
Key Findings ................................................................................................................................ 2
Pre-Crisis WASH Situation .......................................................................................................... 2
Limitations Measuring the Ebola Impact on WASH ..................................................................... 5
Known Impact of Ebola on WASH ............................................................................................... 5
Probable Impact of Ebola .......................................................................................................... 10
Aggravating Factors .................................................................................................................. 12
Risks .......................................................................................................................................... 13
Information Gaps ....................................................................................................................... 16
Lessons Learned ....................................................................................................................... 16
Annex 1 - Background on the Ebola Response ......................................................................... 16
There have been 26,339 cumulative Ebola cases as of 4 May 2015, with 10,895 deaths
(WHO, 05/2015). However, the outbreak shows signs of subsiding. At the end of April,
Guinea reported under 30 cases a week, Sierra Leone under 20, and Liberia declared
the outbreak over on 9 May 2015 (WHO, 05/2015). The crisis has highlighted the
weaknesses of existing infrastructure and institutions, which have not been able to
respond to the additional strain. Many, like the health system, have been weakened
further.
The Ebola outbreak appears to have had a limited short-term impact on the WASH
sector. Delivery of WASH services in Sierra Leone and Liberia were, for example, far
more affected by civil war during the 1990s and 2000s. Despite WASH being addressed
by the Ebola response (see Annex 1), it necessarily remained secondary to the health
sector. Assessments have been planned to scrutinise the impact of Ebola as a whole,
at least in Liberia, but there are almost none completed to date. This, coupled with the
limitations of available information, has led to a sporadic and an incomplete picture of
the exact impact of Ebola on the WASH sector in all three countries.
Yet its impact must not be ignored. Pervasive unhygienic conditions and use of unsafe
water have been identified as a key underlying factor in thousands of deaths prior and
during the Ebola outbreak. In the medium to long-term, lack of development in the
WASH sector is a constant burden to the three countries’ recovery and development.
Addressing WASH development offers the opportunity to greatly increase the quality of
life. In Liberia it has been estimated that improvements to the water supply could reduce
diarrhoea morbidity by 21%, while improved sanitation facilities could reduce diarrhoea
morbidity by 37.5% (Liberian Dialogue 2015/03).
This document summarises the baseline data on WASH available for each country. It
then provides an overview and analysis of the known and probable impacts of the Ebola
outbreak on the WASH sector at both the community and facility level. Relevant
aggravating factors not linked to Ebola are described, and WASH-related areas that
present a possible risk to the people of Liberia, Sierra Leone, and Guinea are
highlighted. Information gaps and lessons learned are outlined at the end.
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Key Findings
Known
impact



Probable
impact
Aggravating
factors
Risks

Pre-Crisis WASH Situation
During the crisis people had to explore alternative water
sources and sanitation facilities, particularly if in quarantine.
However, it is believed the impact on access to water and
sanitation facilities for was limited for the majority.
Very little baseline data is available on WASH from before the Ebola outbreak in all
three of the most-affected countries. Those development indictors relating to WASH that
pre-date the Ebola crisis, were among the worst in the world.
Uncollected waste has built up due to logistical and movement
restrictions, increased by the need to safely manage the waste
from the response.
Investment in and monitoring of WASH activities in health and
education facilities has increased.
The WASH response has focused on new structures rather
than maintenance of existing ones. A focus on facilities has
drawn resources away from communities. This has impeded
development and could lead to an increase in non-functional
facilities by halting the little ongoing maintenance activity.

Ebola facilities have added to the demand on weak WASH
systems, causing environmental damage through waste and
incineration.

Remote rural areas and urban slums are the most vulnerable
and most affected by a weakened WASH sector.

Improved WASH in facilities and improved community hygiene
may be positive consequences of the Ebola response.

The rainy season brings a risk of flooding and increased
waterborne disease. The dry season sees fewer functional
facilities and decreased access to water.

Limited data available, or reliable monitoring systems, to
measure the impact on WASH, especially at the community
level. This has made planning the response problematic.

Lack of investment, limited implementing capacity, and a
diversion of resources from WASH to the Ebola response.

Cholera and other waterborne diseases are endemic in the
region. Should an outbreak occur now, there could be a very
high rate of infection and mortality.

Lack of physical access and movement constraints as a result
of the rainy season might have an impact on the response to
Ebola and other outbreaks.
Access to improved
water sources
Access to improved
sanitation
Open defecation
Liberia
(2013)
Urban
Rural
86%
57%
Sierra Leone
(2013)
Urban
Rural
88%
47%
Guinea
(2012)
Urban
Rural
95%
66%
26%
5%
22%
6%
65%
15%
25%
71%
7%
26%
1%
25%
Sources: LDHS 2013; SLDHS 2013; GDHS 2012.
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Infrastructure: The massive influx of people into Monrovia and other towns over the
last decade puts pressure on an already failing and inadequate water and sanitation
infrastructure in all urban areas (WASH SPR, 2013).
More than 60% of over 10,000 improved water points mapped nationally were fully
functional in 2011 (WASH SPR, 2013). Only 50% are functional throughout the dry season.
Montserrado (98%) and Bomi (95%) have the highest coverage, and Rivercess (47%)
and Bong (54%) the lowest (Liberia Waterpoint Atlas, 2011). In urban areas, 64% of people
get their water from a protected well, and 14.5% from a piped system (WASH SPR, 2013).
Liberia WASH Pre-Crisis
Water supply: Levels of access to improved water supply have fluctuated in recent
years: from 56% in 2007 to 66% in 2011, and down again to 56% in 2013. These figures
are drawn from the Liberia Demographic and Health Survey (LDHS) in 2007 and 2013
and the Malaria Indicator Survey (MIS, 2011). WASH indicator definitions differ slightly
among the surveys, which makes comparison difficult (WASH SPR, 2013).
The situation in urban areas seems to have been more stable, with the same surveys
reporting 81% in 2007, 80% in 2011, and 85% in 2013. With the increase in the urban
population and migration from rural areas, this may actually indicate a higher rate of
improvement. In comparison, rural communities have the same level of access in 2013
as they did in 2007, 56% (LDHS, 2013; 2007: MIS 2007).
Nationally, the proportion of people travelling for more than 30 minutes to collect
drinking water increased from 7% to 18% between 2007 and 2011 (WASH SPR, 2013).
Inequitable access to rural water points exists among clans. Access to services are
particularly low in the southeastern counties, namely Grand Gedeh, Grand Kru,
Maryland, River-Gee, Sinoe and Nimba.
Sanitation: Like water supply, variations in definitions among sources make it
impossible to conclusively measure the increase in access to sanitation. However,
improvement is more evident in sanitation than water supply. Access to improved
sanitation, with household-exclusive use of a facility, shifted from 11% in 2007, to 10%
in 2011, and 17% in 2013 (LDHS, 2013; 2007: MIS 2011).
As of 2013, 25% of people in urban areas openly defecate, and 71% in rural areas. This
is by far the highest of the three countries, demonstrating both the urban/rural disparity,
and lack of infrastructure (DHS, 2013; 2007: MIS 2007). In urban areas, 19% of the population
had access to an improved sanitation facility in 2011, increasing to 26% by 2013. This
improvement is further supported by a reduction in the number of people without access
3
to shared or improved facilities, falling from 47% to 41% in the same years (LDHS, 2013;
2007: MIS 2007).
In rural areas, only 2.2% of the population had access to improved facilities in 2011,
increasing to 5% in 2013. In the same year, 79% still had no access to shared or
improved facilities (down from 85% in 2011) (LDHS, 2013; 2007: MIS 2011).
Waste management is largely restricted to Monrovia (GoL 2013). Still, the sewage system
only covers around 14% of the city and has not yet been restored to pre-civil war
capacity, which would be inadequate because of the expansion of the city’s population
since then (WASH SPR, 2013). The most recent data, from 2007, shows that 55% of the
capital’s solid waste was not being collected. The remainder was being discarded in
waterways and empty land (Bill & Melinda Gates Foundation 2009, Innis 2015).
2015. The same report stated that the water supply is increasingly polluted as a result
of contamination by human and industrial activity (UNDP, 2009).
Waste management: Even before the Ebola outbreak, Freetown suffered from
increasing waste and decreasing waste management capacity. It was estimated in 2013
that Sierra Leone’s cities produce about 0.3 million metric tons of solid waste per year,
with Freetown contributing 800 metric tons a day in 2010 (local media, 21/06/2012). 40% of
Freetown’s waste is collected in formal disposal sites by private operators. The rest is
burned at home or disposed outside in waterways, drainage channels, alongside roads
and vacant lands (Freetown WASH Consortium, 2013). This results in flooding and an
increased transmission of vector-borne diseases.
Hygiene: According to the 2013 LDHS, only 2% of households have hand-washing
facilities. Of those, 47% had water and soap, 19% had only water, and 5% had soap but
no water (LDHS, 2013).
Hygiene: Prior to the Ebola crisis, 22% of households had a place to wash their hands.
That number increased to 33% in urban areas and 17% in rural areas. However, of
those that had a place to wash hands, only 33% had soap. This represents 55% in urban
areas compared to 12% in rural areas (SLDHS, 2013).
Sierra Leone WASH Pre-Crisis
Guinea WASH Pre-Crisis
Water supply: The 2013 DHS reported that 89% of households in urban areas had
access to improved sources of drinking water and only 48% of rural households. In
urban areas, there is a large discrepancy in access to improved facilities between
wealthy and poor households (Freetown WASH Consortium, 2013). For the majority of the
population, water is rationed. Almost no households have a 24-hour water supply.
It is worth noting that the WASH Cluster had been activated in Guinea prior the Ebola
crisis, highlighting the concerns regarding the WASH sector before the outbreak.
Guinea has the highest development indicators of the three countries for WASH.
Infrastructure: According to a 2012 water point survey, 65.5% of water points were
reported to be in use, but only 39% (11,212 points) were functional and in use yearround. In some districts, the percentage of protected/in-use water points fell below 45%
Water supply: The GDHS reports that 75% of households have access to improved
drinking water sources, 39% of them wells with pumps or boreholes. 95% of urban
households use an improved drinking water source. According to the GDHS, only 66%
of households in rural areas have access to an improved water source, 51% of which
use boreholes. These are higher proportions than Liberia and Sierra Leone (GDHS, 2012).
(UNICEF, 2012).
The uneven distribution of water points within districts creates yet more discrepancies
between individual communities’ access to water. It was estimated that about 50% of
the water supply in Freetown is unaccounted for, lost through leakages and illegal use
(UNICEF, 2012).
Sanitation: Before the Ebola crisis, only 10% of households had an improved toilet
facility not shared with other households. In urban areas, 22% had access to improved
sanitation in 2013, which marked a decrease from 26% in the 2008 SLDHS. In rural
areas, access decreased from 7% to 5% (SLDHS, 2008; 2013). 7% of people in urban areas
and 26% in rural areas defecate openly (SLDHS, 2013; Wateraid, 2012). As with the other
countries, the capital, Freetown, has the only significant a sewage system. However, it
is antiquated and cannot meet current demand.
In 2009, UNDP estimated that about 1.7 million people would still be without access to
water supply services and 2.2 million would be without proper sanitation facilities by
In Conakry, almost all households are using safe water sources (99%). The lowest
coverage is in the regions of Kindia (44%) and Mamou (43.3%). In rural households,
only 10% have a water source on premises. 40% spend more than 30 minutes fetching
water, compared to 18% of urban households (GDHS, 2012).
Infrastructure: Only 80% of draining pumps were seen to be in good condition in 2012.
There is lack of capacity to provide the training or technical support necessary for
maintenance. According to the national poverty reduction strategy, DSRP, this has
resulted in a deterioration in access to improved water and latrines (DSRP, 2013).
Sanitation: The GDHS reports that 56% of households use non-improved toilet
facilities. 29% of rural households do not have access to any kind of toilet facility.
Faranah (77%) and Mamou (71%) regions had the highest proportion of unimproved
toilet facilities, and Conakry the lowest (8.7%). Open defecation is most common in the
regions of Labe (48%), Mamou (33%) and Nzerekore (33%). The DSRP states that 31%
of the population live in households using improved sanitation facilities: 65% in urban
4
areas and 15% in rural areas. In urban areas, under 1% practice open defecation, while
this figure is 25% in rural areas (GDHS 2012; DSRP 2013).
Waste management: There is no well-established system for solid waste management.
70% of households dispose of their waste in the environment. This proportion is lower
in urban areas (47.1%) than in rural areas (80.2%). Conakry is the only region with a
waste management system, either via private or public waste bins or truck collection.
Incinerators are another common way of handling solid waste (INS, 2012). The
management of household waste remains a challenge. In urban areas the percentage
of households disposing of its waste hygienically declined by more than 10% between
2007 and 2012 (DSRP 2013).
The lack of urban planning, especially in Conakry, has given rise to a highly polluted
environment. Domestic waste water, sewerage, solid waste and toxic medical waste
from hospitals remain largely untreated and are a major concern for environmental
health (DSRP, 2013).

The lack of baseline data from prior the outbreak for aspects of the WASH sectors
priorities in the response, such as WASH in facilities.
ACAPS must also note that there was a general lack of information available on Guinea.
This is partly due to ACAPS’ relatively limited time in-country, but also due to a clear
gap in national and institutional data on the Ebola impact.
Where information is lacking – most frequently in Guinea – we triangulate other sources
of information to deduce if an impact can be generalised to the whole region, and define
the limitations of such generalisations.
Known Impact of Ebola on WASH
Hygiene: Although there were efforts to improve practices in recent years, according to
the GDHS, only 41% in urban areas and 31% in rural areas had hand washing facilities.
However, only 37% and 9% of those households, respectively, use soap and water
(GDHS, 2012). The DSRP reports that 48% of people washed their hands at all times after
using the toilet (DSRP, 2013).
The following breakdown of the known impacts of Ebola on the WASH sector during the
crisis is based on WASH data available, baseline statistics, interviews conducted by
ACAPS analysts in the field, and trends evident before the crisis. The impact of Ebola
is defined as ‘known’ if there is substantial evidence to support the conclusion. This
could be in the form of uniformed consensus from sources, but preferably from the
findings of formal assessment; these have most frequently been conducted for facilities
rather than at community level.
Limitations Measuring the Ebola Impact on WASH
For a background on the main focus of the WASH response during the Ebola outbreak,
please see Annex 1.
Some areas have been monitored during the crisis. There is also significant evidence
from which to draw conclusions regarding the likely, if not provable, impact of the Ebola
outbreak on WASH in the three affected countries.
Nonetheless, there are several issues with measuring the impact of the Ebola outbreak
and the response on the WASH sector in the three most affected countries.




The lack of data for many aspects of the WASH sector that were potentially
impacted, such as maintenance of facilities and services.
The limited geographical scope of assessments conducted during the Ebola
outbreak, which often were not representative at the national level.
Variations in definitions and methodology of assessments, making collation or
comparison of data difficult. This is especially true for comparing assessment over
years, organisations, and countries.
Humanitarian actors’ bias towards data collection during the outbreak, which has
focused on those WASH priorities already identified in the recovery and response
strategy, rather than attempting to get a holistic view of Ebola’s impact on WASH
more generally.
Community
Restricted movement/Quarantine: With Ebola, movement restrictions aggravated
lack of access to water across the three countries. At different times during the outbreak,
most often in Sierra Leone, whole areas were quarantined. At other times, most
frequently in Liberia, individual households were in quarantine. In addition, there were
broader restrictions on movement and nationwide curfews. These restrictions have
largely been removed in the current phase of the response, or only impact a small
number of people. Nevertheless, at the outbreak’s height they severely affected
people’s access to WASH facilities.
In Sierra Leone, 17% of the population surveyed in October 2014 stated that Ebola had
affected the provision of water services (UNDP, 01/2015). Several maintenance routines
were stopped and water trucks’ access was limited (IRIN, 14/10/2014). People were forced
to look for alternative, unprotected sources of water, and the risk of water-borne disease
increased (PI, 01/2015).
5
The restrictions and closure of borders hampered imports of essential products, such
as chlorine for water treatment, and the movement of skilled personnel, such as
maintenance teams and Infection Prevention Control (IPC) professionals (Early Recovery
Strategy, May 2015).
Ebola waste: Concerns have been raised about the medical waste created by facilities
in an already grossly undercapacity national waste management system, as well as the
environmental impact of incineration and the large quantities of chlorine used.
Every visitor and healthcare professional working in an Ebola facility was required to
wear personal protective equipment (PPE), which was removed and disposed of after
duties in the facility which presented a risk of infection. This means over four PPE kits
per patient per day. Currently, the medical waste management practices in health
facilities in each of the countries is based on burning all waste within the same
compound, and segregation of sharps waste, such as needles, into a hole that is
covered with concrete (PI Sierra Leone, 03/2015).
This same practice is used in Ebola facilities. PPEs and other contaminated materials
have caused a spike in the amount of medical waste that must be burned at very high
temperatures. Some Ebola treatment units (ETUs) have had to burn this waste in piles
in the open air, raising concern in neighbouring communities and causing environmental
damage (WHO 02/2015).
Liquid waste is also a challenge, as 300 litres are generated per bed per day in an Ebola
treatment unit, including sewage and the chlorinated water used for IPC activities. In
Liberia, only the Fiamah sewage plant in Monrovia was able to receive this waste (WHO,
Guinea, beginning on 12 April and targeting 500,000 households may result in a greater
waste build-up in Guinea (USAID, 04/2015).
Development programmes impeded: Following the outbreak, many stakeholders
working on WASH have had to redirect resources and activities towards supporting the
Ebola response.
In Sierra Leone, the Guma Valley and Sierra Leone Water Company SAWALCO have
put investments to expand water provision services on hold, and some INGOs have
reduced their WASH development activities (UNDP, 01/01/2015; PI Sierra Leone 04/2015; ACF
04/2015).
Furthermore, it is estimated that 800,000 consumers in the Sierra Leone districts of Bo,
Kenema, and Makeni will not benefit from the Three Towns Water Supply Project,
intended to improve water supply and sanitation capacity and service delivery. This
project will be delayed for at least one year as a result of the need to shift national and
international focus to the Ebola response. UNICEF rural WASH projects, aiming to drill
additional boreholes, re-establish community-based water management, and promote
hygienic behaviour, have also been disrupted, affecting more than 5,000 communities
(Early Recovery Strategy group, 02/2015).
In Guinea, the goals of the few existing projects have been similarly severely
undermined. The Poverty Reduction Strategy for Guinea, begun in 2007 and updated
in 2012, intended to construct thousands of new water points and latrines, and extend
the Conakry sewage system. Development funds for WASH have been redirected for
EVD response (Early Recovery Strategy 2015).
ICRC 2015/02).
Several actors have emphasised the need to monitor the cemeteries where people who
died from Ebola have been buried, as well as the burial sites for ETUs’ medical waste
and their septic tanks. The community may consider these areas to be sources of
infection and they may present a challenge to the reuse of nearby latrines and wells (PI,
04/2015; PI, 03/2015). However, the exact scale of the issue is yet to be assessed.
Non-Ebola centres’ waste: The considerable accumulation of waste during the
outbreak has not solely come from Ebola treatment facilities. It has been reported that
a large amount of waste has accumulated in towns in Sierra Leone (PI, 04/2015). A
major factor contributing to this build-up has been the lack of collection during
lockdowns and quarantines.
Nearly 50% of Freetown was placed under quarantine during the outbreak. The large
volume of accumulated waste cannot be incinerated without causing major
environmental damage. Given the low baseline indicators for waste management in all
three countries, similar build-ups can be expected in Liberia and Guinea. Guinea, where
case numbers and movement restrictions were less severe, is likely to be less affected
than the other two countries. However, the recent series of stay-at-home periods in
Health and Education Facilities
Though information is limited, it is uniformly recognised that WASH conditions in both
health and education facilities were of a very low standard prior to the outbreak. As
such, it was a major concern as a means to slow infection rates, especially for health
facilities.
Most WASH-related aid efforts were focused on facilities rather than communities.
Actors saw the immediate improvement of WASH standards in facilities as the most
achievable goal. This was expected to have a more significant impact than
improvements at the community level.
Schools were closed for several months in the three countries as part of government
efforts to curtail the spread of the outbreak. During the closure, many schools’ resources
were taken by the community and school’s WASH facilities were often used by
communities, resulting in deterioration of latrines and other existing WASH
infrastructure. The current level of WASH in schools is unclear. Coupled with the lack
of baseline data, this makes it difficult to ascertain the exact impact of Ebola.
6
Liberia Health Facilities
Liberia is the only country where substantial baseline data for health facilities is
available. According to data from the 2013 MOHSW Facility Accreditation, 84% of the
659 health facilities reviewed had running water for hand washing and 98% had
available drinking water. No comprehensive sanitation or waste management data is
available. However, 76% reportedly had sanitation facilities for patients, 82% burial pits,
and 72% incinerators (MoH, 2013).
The factors behind a particular county’s performance are unclear: there does not appear
to be a particular correlation between facilities that have functioning water sources and
those that have functioning toilets. For example, Grand Kru and Sinoe had the highest
number of functioning water sources, but also the fewest functioning toilets.
Sierra Leone Health Facilities
In Sierra Leone, according to a recent UNICEF health facilities survey in April 2015,
71% of primary health units have access to water throughout the year, whilst 14% have
no access at all. Tonkolili (35%), Pujehun (27%) and Kambia (26%) have the worst
levels compared to the national average. All facilities reported hand-washing facilities
are available on site, but only 39% have a functional incinerator. The main means of
waste management seems to be burning pits: 88% have access (UNICEF, 04/2015).
By February 2015, 43 of 50 (86%) assessed Ebola health facilities in Sierra Leone met
minimum standards for IPC (WHO, 11/02/2015).
Guinea Health Facilities
A 2014 government WASH inventory of 398 health facilities in 32 of Guinea prefectures
found that only 61% had access to a functional water point. 8% had water points that
did not function, and 31% had no water point at all. 90% had access to functional
latrines, with 7% having access to non-functioning latrine and 3% without any access.
Only 10% had access to incinerators (Guinea WASH Cluster, 02/2014).
The WASH Cluster conducted another assessment of WASH in 647 health facilities in
March 2015. 50% did not have a protected year-round source of water, and 20% did not
have any protected source on site. 74% of available water sources were functional
(WASH Cluster, 04/2015).
96% of health facilities had toilets, but only 91% of those facilities had functional toilets.
43% of health facilities did not have an incinerator or other waste management system
and only 23% had a drainage system. 61% of facilities reported hand washing facilities
at the toilet (WASH Cluster, 04/2015).
Assessments conducted during the Ebola outbreak are not as nationally representative
as the government WASH inventory. However, they do provide an indication of the
current state of WASH in health facilities. UNOPS conducted an assessment of 42
priority health facilities from all four geographic regions of Guinea in April 2015. They
found that most priority facilities, apart from Guinée Forestière, have access to a latrine.
However, over half were non-functional. Far more priority facilities lack any water points,
with no priority facilities in Moyenne Guinée reporting access to a water point – although
only three priority facilities were assessed in the region and so the severity of the
situation is likely exaggerated by these findings. Seven out of ten priority facilities in
Guinée Forestière have no access to a water point, which is far more likely to indicate
the general level of access given the low development indicators in the region. Only one
facility in Guinée Forestière had a functional water point. In Basse Guinée and Haute
Guinée, 20% and 40% of priority facilities had functional water points, respectively
(UNOPS, 04/2015).
A pilot survey in 2015 led by the National Society for Sanitation and Water Points Project
and Dutch NGO AKVO assessed 41 health centres in Boké and Kindia prefectures.
Results show that only 49% had access to functional water points, 22% had access to
a water point that was non-functional, and 29% had no access. This assessment also
7
found only 46% of health centres could access a functional latrine, with 36% of latrines
non-functional (Guinea WASH Cluster, 04/2015).
Margibi, Monteserrado and Grand Bassa counties, while the poorest performers were
Sinoe, Grand Kru and Gbarpolu (WASH SPR, 2013).
Both surveys suggest that health facilities are more likely to have access to latrines
that water points.
The baseline survey has limitations, as it was completed by school head teachers
instead of WASH technicians. Therefore there might be issues of reliability. Disparities
between primary and secondary school results might be the result of the larger size of
the secondary schools that often have more space for WASH facilities.
The only nationally representative assessment for WASH in schools conducted during
the crisis was carried out by the Education Cluster in March 2015. It found that 60% of
the assessed schools have safe drinking water within 500 meters. 31% did not have a
functional latrine (Education Cluster, 02/2015). Schools with functional latrines have an
average of 1 latrine for every 123 students. However, an Oxfam report found that even
when facilities are available, they often cannot be used due to damage or unhygienic
conditions, causing children not to feel safe using them (Oxfam, 03/2015).
40% of the schools have soap and water for hand washing, and 39% of the schools
have functional hand washing facilities. This is an increase from the around 18% who
had hand washing facilities before the outbreak, according to Oxfam. If accurate, this
could be due to the focus of responders to improve IPC in schools. (Education Cluster,
02/2015).
44% of the assessed schools reported that their WASH facilities were used while the
school was closed, especially the latrines. Therefore the deterioration of WASH facilities
in schools during the Ebola outbreak can partly be attributed to the use of school latrines
and water points by the community and a lack of regular maintenance.
Schools in Sierra Leone
UNICEF reported in 2012 that only 20% of schools in rural areas of Sierra Leone had
access to improved water (UNICEF, 2013). A national assessment carried out in March
2015 indicates variance between districts. The highest use of unimproved water sources
was in Tonkolili at 83.4%, followed by Kailahun at 80.2%. Western Urban Area reported
the lowest use of unimproved water sources, at 41.2%. The other districts ranged
between 43% and 61% (UNICEF, MEST, 02/2015; Education Cluster, 02/2015).
Schools in Liberia
As with health facilities, Liberia is the only country with available baseline data for
schools prior the Ebola crisis. A 2013 Ministry of Education report on the WASH sector
is the best pre-crisis data available. It found that access to water in primary school was
particularly low, with a national average of 45%. Only five counties had 50% or more of
primary schools with access to water. Nationally only 67% had access to a latrine. This
is compared to secondary schools, where 67% could access water and 89% had access
to a latrine. Overall, according to this assessment, the highest indicators were found in
8
Most schools assessed in the same report used soap and water, with the highest
proportion found in Bonthe (64.4%) and Kailahun (64.2%), and the lowest in Koinadugu
(10.7%). The majority of other districts ranged from 40% to 60% (UNICEF, MEST, 02/2015).
50.9% of schools used an open pit as the method of waste management, the second
most common method being dustbins (UNICEF, MEST, 02/2015).
Schools in Guinea
Source: Education Cluster
There is a strong correlation between the type of school, the availability of functional
latrines, and available safe drinking water. The disparity between primary and
secondary school results, as with Liberia, might be the result of the larger size of the
secondary schools providing more space for WASH facilities, but institutional size does
not explain the disparity between pre-primary and primary schools.
9
According to data collected by the Education Cluster in Guinea, 84% of secondary
schools have access to latrines, while only 53% have access to water – either on the
premises or nearby. Similar WASH data for primary schools is not available (Education
Cluster, 03/04/2015). The situation of secondary schools appears to be better than that of
health facilities. Access to a latrine is more likely than access to a water point in both
places. The conditions and functionality of latrines have not been reported, and results
are not conclusive. The sample sizeable but not complete, and the data available for
Conakry was too incomplete to draw a reliable conclusion. The findings should be
considered only an indication of the current situation.
Probable Impact of Ebola
The impact of Ebola is defined as probable when there is sufficient evidence to indicate
strongly that the Ebola crisis has impacted the WASH sector, but there is insufficient
baseline or current data available to state that it is known.
Community
Improved hygiene practices: One of the few likely positive impacts of the Ebola
response is community engagement’s effect on attitudes towards hygiene and
sanitation. Knowledge, Attitudes and Perception (KAP) surveys in Liberia and Sierra
Leone indicate that there has been an improvement in hygiene and sanitation practices.
In Sierra Leone, where the SLDHS provides evidence for hand-washing practices prior
to the outbreak, some districts have seen a significant increase in hand-washing.
Compared with the 2013 SLDHS, the January 2015 IFRC KAP survey, the proportion
of people in Koinadugu reporting regular hand-washing with soap and water has
increased from 5% to above 90%. Numbers in Kono and Port Loko have grown from
22% and 26%, respectively, to above 70% (IFRC, 01/2015, SLDHS, 02/013). This positive
outcome could possibly have resulted in improved hygiene conditions and lower
transmission of diseases like diarrhea.
Actors have used this probable improvement in attitudes to emphasise the critical role
of community engagement and behaviour change, and as a warning to not solely focus
on infrastructure rehabilitation projects.
It is not possible to say for certain whether these positive shifts will be restricted to the
duration of the Ebola outbreak, or to specific districts. There are also very few KAPs
which were repeated over time, therefore it is not possible to record how community
engagement impacted hygiene practices over time.
In the case of Guinea, lack of available information makes it more difficult to predict
impact. Given the higher level of resistance to the response in Guinea, it is reasonable
to suspect that the impact has been less significant (ACAPS, 04/2015).
Poor build quality and lack of maintenance: Lack of maintenance and the disruption
of development programmes together present arguably the biggest consequences of
the Ebola outbreak upon the three countries’ WASH sector. The Ebola outbreak
reduced what little maintenance that was being carried out in the community to nearly
zero. The redirection of resources towards health, education and Ebola facilities for a
year may well lead further deterioration of WASH facilities and monitoring systems,
especially in communities as they were not the focus of Ebola WASH response.
Chronic lack of maintenance was a long-term and severe obstacle to development in
Guinea, Sierra Leone and Liberia long before the Ebola crisis. Pre-Ebola WASH
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programmes placed too much emphasis on coverage, and not enough on sustainable
service delivery. In general, the construction of new infrastructure projects has
superseded the capacity to maintain these structures, and has not considered the
burden of the cost of maintenance (PI Sierra Leone, 04/2015).
The DSRP states that lack of maintenance is the reason access to improved sanitation
facilities in Guinea declined by 1.1% between 2007 and 2012. More significantly, access
to water points fell from 74.1% to 68.6% in the same period. In rural areas the decrease
was from 67.8% in 2007 to 57.1% in 2012, while urban areas saw an improvement from
90% in 2007 to 92.9% in 2012 (DSRP, 2013).
Poor maintenance means that gains achieved by investment are quickly lost. For
example, between 2009 and 2010 the number of new water points in use increased
from 0.24% to 1.4% due new constructions in rural areas. In 2011, this number had
decreased to 0.7%, as a very large number of wells were no longer functioning. This
could also be due to poor construction (DSRP, 2013).
facilities in Guinea, it is possible that communities and private individuals are the best
performing group in that context as well.
Without the support and training of the community and private individuals, the shortterm boost of the large presence of international actors to WASH sector capacity is very
likely to diminish. This is aggravated by people’s reluctance to use WASH facilities that
have been associated with Ebola infections, as well as the poor build quality and lack
of maintenance of WASH infrastructure leading to an increase in non-functionality.
Water supply to Ebola treatment facilities: Each Ebola facility requires between 200L
and 400L per day per patient. This likely meant a huge diversion of water from the local
population to Ebola centres, particularly in big urban areas. The exact number of people
affected by the diversion is unknown. In Freetown, it was estimated that between 1.3%
and 15% of water was diverted (PI 04/2015; PI 02/2015; WHO 02/2015).
As the majority of Ebola facilities have now been decommissioned, and those that
remain have minimal patients, this impact has probably subsided. However, the strain
on infrastructure may have longer-lasting effects.
Urban Areas: Slums
According to responders in the field, the Ebola emergency has exposed the
deterioration of capacity and quality of WASH services in urban centres. It has
highlighted the gap in service provision to vulnerable communities, especially to the
residents of the three countries slums.
In all three countries, WASH standards in slum areas are among the lowest, while the
high population density makes the population most susceptible to waterborne diseases.
Slum areas are often also more likely to flood due to their topography. Poor or nonexistent safe water and sanitation facilities are also linked to high malaria and diarrhoea
rates (Cities Alliance, 2008).
During the Ebola response, the lack of safety protocols and trained sanitation
technicians were highlighted as major gaps in sanitation infrastructure and services (PI,
27/03/2015).
In Liberia, a third of water points built since 2004 were non-functional in 2011 (Liberia
Waterpoint Atlas, 2011). In Sierra Leone, post-war emergency interventions reportedly did
not prepare the communities for their maintenance. This, and a lack of minimum quality
standards for construction, is blamed for the low water point functionality of
approximately 62% in 2012 (AfDB, 09/2013). It is significant to note, however, that in the
case of both Sierra Leone and Liberia, the water points that were most likely to be
functional were those constructed by the community or private individuals. UN agencies
performed worst in Liberia and private companies in Sierra Leone (Liberia Waterpoint Atlas,
2011; Sierra Leone Waterpoint Report, 2012). Given the evidence of deterioration of WASH
The density of urban slums also meant their populations were more adversely affected
by the direct impact of burning and burial of waste in their vicinity.
In summary, slum areas have borne the brunt of the Ebola impact among urban
populations, and have been made them more vulnerable to WASH-related dangers as
a result. These concerns are particularly true for Freetown and Monrovia, where
baseline statistics have been lower and restrictions of movement have been more
frequent, and where Ebola case numbers have been higher than Conakry.
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Rural Areas
Declining infrastructure due to weak maintenance is expected to have had a particularly
detrimental impact in rural areas affected by Ebola The rural/urban disparity in access
to improved drinking water sources is already very wide. Remote communities have to
travel further and have more logistical challenges finding alternative improved facilities
and safe drinking water. They are also the least likely to benefit from any international
response (Stratégie de relance, 2015).
Facilities
Like hygiene practices, facilities are likely to improve in the short-to-medium term. This
is due to the attention they have received from humanitarian responders. Some NGOs
have already planned or started implementing projects to improve WASH facilities
beyond the scope of the Ebola response.
Based on previous records of WASH facilities maintenance, it is unclear how long these
improvements will continue beyond international actors’ withdrawal. In Liberia, there is
a risk that the new water points, latrines and other WASH infrastructure constructed in
schools, health posts, and local markets will not be provided with water, hand-washing
facilities, or latrines, which might defeat the purpose of the infection and disease control
measures which have previously been put in place as part of the Ebola response and
by the national authorities (PI, 27/04/2015).
Furthermore, actors have warned that interventions by international actors often bypass
governmental structures and systems. They provide urgently needed services to
communities, but risk further erosion of local capacity (World Bank, 04/2015).
Aggravating Factors
Lack of investment and disbursement bottleneck: There has been a long-term lack
of investment in national WASH programmes in all three countries.
In Liberia in 2012/13, only 1.2% of the Liberian government budget was allocated to
WASH. The planned 2013/14 budget was even lower, at 0.4% (WASH SPR 2013).
Lack of data and monitoring systems: Population projections based on census data
do not reflect variations in average population growth in urban areas, or at national level.
Since the data does not accurately reflect the number of people in need of WASH
support, the scope and funding of programmes are routinely underestimated.
An effective and sustainable monitoring system for the functionality of water points and
latrines remains lacking (Adam Smith International, 04/2015). Monitoring systems were
abandoned during the civil wars in Sierra Leone and Liberia, and have not been
adequately resurrected.
The rainy season: All three countries experience floods almost yearly during the May–
October rainy season. Along with posing a threat to the lives of the most vulnerable,
flooding also damages property and infrastructure. Low-lying slums, common in West
Africa’s urban areas, are particularly vulnerable to flooding due to poor drainage, with
contaminated water contributing to the spread of waterborne diseases, including cholera
(Overseas Development Institute, 01/2014).
In Guinea, the last floods which causes significant damaged happened in August 2011,
and mainly affected the prefectures of Labe and Siguiri and areas of Conakry. At least
1,920 houses were damaged or destroyed, as well as 542 latrines and 212 wells, which
had become unusable (IFRC, 29/11). At the time of publication, May 2015, there are
reports that people living in flood-prone, low-lying parts of Conakry are moving to other
locations in preparation for the wet season (PI, 05/2015).
In Sierra Leone it has been reported that flooding overwhelms existing systems.
Contamination of drinking water and sewage overflows are common during the rainy
season (Wateraid, 2012).
The dry season: The water table drops across the three affected countries during the
annual dry season. It has already affected the Ebola response, with 35% of 121 Ebola
facilities in Sierra Leone found to have inadequate water supply during the dry season
(UNICEF 29/01/2015). Up to 40% of the protected in-use water points provide insufficient
water in dry season in Sierra Leone. This is generally due to insufficiently deep wells or
an inappropriate choice of water point location. The limited availability of safe water in
the dry season means more people share the same water supply, which results in
increased per capita water contamination, especially in densely populated areas (Ministry
of Energy and Water resources, 2012).
In Sierra Leone, the sanitation budget has been especially underfunded. There is
usually a delay in the disbursement of funds to ministries, departments, and agencies,
despite the Government having timelines for planning and budgeting (Budget Advocacy
Working Group, 2013). This has led to underfunded and inefficient implementation of
government WASH programmes (PI Sierra Leone, 04/2015). This point can be generalisable
to an extent to Guinea and Liberia.
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Map of Seasonal Variations in Access to Water points
in Sierra Leone
actors, as their presence is providing vital support to what remains of both the national
WASH and health sector.
Cholera
Liberia
The Ebola outbreak in Liberia is over, and so the impact of overlapping outbreaks of
cholera and Ebola is no longer a threat, unlike in the other two countries. In Liberia,
WHO reported 207 cholera cases in 2012 and 102 in 2013. In previous cholera
outbreaks, most cases were reported in Montserrado. Although no cholera cases have
been reported so far in 2015, this does not exclude the risk of an outbreak following the
rainy season, particularly in the face of a health system weakened by Ebola and a near
non-existent WASH monitoring and maintenance system.
Sierra Leone
Source: Sierra Leone Waterpoint Report, 2012
The map above indicates the level of access to a functioning improved water point in
the dry and wet seasons for Sierra Leone. Guidelines from the Ministry of Energy and
Water resources (2012) state that access should not go above 250 people per water
point. It demonstrates how far this number is exceeded across Sierra Leone.
The 0.1ºC average increase in temperature each year, which may extend the dry
season as well as making the rains heavier during the rainy season. This will cause
more flooding and potentially extend the periods where the water table’s depth affects
water access (PI Sierra Leone, 04/2015).
Risks
Flooding during the rainy season dramatically increases incidence of cholera and other
waterborne diseases throughout the three countries. Cholera is endemic in all three
countries. According to WHO, the risk of an outbreak of another disease before Ebola
is eradicated could have an increased impact on morbidity and mortality than would
have been expect by an outbreak prior Ebola. This is because health service delivery
has been weakened and use has decreased (ACAPS, 02/2015). This would present a
particular risk if an outbreak occurred after or during the withdrawal of international
Although having fewer Ebola cases than Guinea, Sierra Leone should also be monitored
for a new cholera outbreak. The last major outbreak was in 2012, affecting around
23,000 people and caused 300 deaths (GoSL MoH, 2012). Cholera outbreaks in 2007 and
2008 were less severe, with 84 deaths and 62 deaths, respectively (WHO, 2013). Cholera
outbreaks in Sierra Leone have tended in the past to start in a coastal fishing community
in Kambia to the north of the country, spreads down the coast by boat and by road to
Freetown, where coastal slums are particularly vulnerable (GoSL MoH, 2012).
A consortium of different NGOs with WASH programmes in Freetown have identified 28
hotspots as particularly vulnerable to poor WASH related diseases. A hotspot was
defined as an area which has had two of the three following criteria: previously recorded
cholera cases, at risk of flooding, and reported Ebola cases. 15 are at risk of flooding
and all 28 have had Ebola cases reported. All of the identified hotspots reported cholera
cases in 2012, apart from Kissy Mental which is still considered at high risk of cholera
due to its dire WASH conditions. Accordion to the same consortium of NGOs, at least
half of the urban population potentially exposed live in the Western Area, including in
the urban and peri-urban slums of Freetown (Freetown WASH Consortium, 04/2015). (See map
of hotspots on page 15).
12 of 21 cholera outbreaks in Guinea between 1970 and 2012 have been cross-border
outbreaks between Guinea and Sierra Leone. Prior to the Ebola outbreak, there were
15 sentinel stations in Forécariah, Boffa, Coyah, Dubréka, Boké and Kindia monitoring
the prefectures for signs of an outbreak (MoH, 2013). These are being reactivated
through the WASH coordination in Conakry.
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Guinea
The risk of a new cholera outbreak is perhaps of the greatest concern in Guinea, where
Ebola case numbers are still high. The last cholera outbreaks were in 2012 and 2013.
The coastal areas are generally those most affected by cholera. The 2012 outbreak saw
7,351 cases and 138 deaths. 2013 was less severe, with 319 cases and 32 deaths, with
Conakry, Mamou, and Dubréka recording the highest case numbers. Of concern is the
spread of cholera in 2013 to locations in the interior of the country, such as Mamou,
where access to improved water and improved latrines is among of the lowest (see
GDHS data above).
No cholera cases were reported in Guinea during 2014. This is likely due to
improvements in hygiene conditions resulting from measures to contain the spread of
Ebola (ACAPS, 02/2015).
12 of 21 cholera outbreaks in Guinea between 1970 and 2012 have been cross-border
outbreaks between Guinea and Sierra Leone. Prior to the Ebola outbreak, there were
15 sentinel stations in Forécariah, Boffa, Coyah, Dubréka, Boké and Kindia monitoring
the prefectures for signs of an outbreak (MoH, 2013). These are being reactivated
through the WASH coordination in Conakry.
Other Water-borne Diseases
Liberia
In Liberia, reported cases of diarrhoea fell from an average of 146 cases per week to
76 cases per week between 2012 and 2013. But there are substantial gaps in data,
meaning the decrease is not certain. 90% of child deaths linked to diarrhoea in Liberia
were directly attributed to poor water, sanitation and hygiene in 2013 (UNICEF, 2013). In
2012, E. coli was present in 58% of Monrovia’s water due to open defecation (Local Media
24/08/2013).
Sierra Leone
14% of the 217 children under five dying per 1,000 live births a year in Sierra Leone are
due to diarrhoea. It is the third cause of infant mortality in the country (Freetown WASH
Consortium, 04/2015). This is partly due to the poor WASH situation for most Sierra
Leoneans.
Guinea
The incidence of diarrhoea in children under five in Guinea is 16% according to the
GDHS 2012. This increases to 25% in children aged 12–23 months. Incidence is higher
among children with reduced access to improved water sources and improved latrines
(GMICS, 2012).
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15
Information Gaps
Annex 1 - Background on the Ebola Response
The following information gaps should be filled in order to gain a more accurate
understanding of the impact of the Ebola outbreak on the WASH sector in the three
affected countries.
The main WASH focuses of the Ebola response has been the following:





WASH indicators at a community level, particularly communities most affected by
Ebola.
The impact of Ebola treatment facilities on the local environment, including liquid
waste disposal, incineration, and general waste disposal.
The impact of Ebola treatment facilities on the local WASH infrastructure.
Nationally representative KAP surveys on hygiene practices in the community
beyond the perspective of the Ebola response.
Data on the impact of Ebola on WASH in Guinea, including information on facilities,
as well as nationally.

WASH in Ebola treatment facilities: The primary focus of responders has been
ensuring WASH standards within Ebola treatment facilities, for the safety of patients
and staff. This has included carrying out IPC protocols, as well as the provision of
water supply and sanitation to patients, and the safe, if not environmentally friendly,
disposal of waste, medical and otherwise.

Social mobilisation: At a community level, one of the major focuses of the
response was to promote better hygiene and sanitation practices. However, actors
trying to promote these changes have been affected by resistance from the
communities. This is particularly true in Guinea (see ACAPS report on Resistance
in Guinea).

Distribution of WASH supplies: In the immediate response, actors focused on
distributing household WASH kits, including chlorine, soap, and other supplies
intended to alleviate and improve WASH standards in affected communities (UNICEF,
Lessons Learned
14/01/2015).

Strengthening non-Ebola health facilities: Providing WASH facilities and
services in non-Ebola health facilities, and schools. This has generally included
improving access to water, sanitation, and proper waste management. It has been
in addition to providing technical support and construction of facilities such as water
points and latrines. As the crisis developed, support included preparing schools for
reopening and the return of pupils: in January in Guinea, February in Liberia, and
April in Sierra Leone.

Safe and dignified burials: Responders have conducted burials of confirmed and
suspect cases during the response. Protocols have changed over the course of the
outbreak, sometimes dramatically, to reflect country and locality-specific custom
and concern. Incineration has, at times, been used over burial.
Maintenance and community ownership are the keys to long-term WASH sector
improvement. It has led to the minimal improvements seen over the last few years, as
well as in some decreasing functionality of infrastructure. Whatever the benefit of the
international Ebola response has been to WASH on the three affected countries, it will
only ever be a short-term improvement without this shift in its approach.
Anticipating the impact of seasonality is crucial to mitigate the worst impact of
the rainy and dry seasons. Their respective effects on water tables, flooding, and the
risk of waterborne disease are well understood across the region. By taking account of
their impact on WASH (including logistical restrictions), their negative influence could
be reduced.
The disparity in WASH indicators between rural/slum areas, verses more relatively
prosperous urban areas has been an outstanding problem for years and is not being
adequately addressed. These issues will only slightly be diminished by short-term
construction projects. WASH project design should emphasise any element that can
provide longer-term solutions to this disparity.
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